Athletic pubalgia is a set of pelvic injuries involving the tendons that attach to the front of the pelvis. Adductor-related groin pain is most prevalent in sports requiring pivoting, cutting, kicking, and change of direction, but can occur in non-athletes as well (Caudil et al, 2008).

Athletic pubalgia is due to weakening of or chronic stress at the common attachment of the distal rectus abdominus and proximal adductor longus tendon (Elattar et al, 2016; Drager et al, 2020; Meyers et al, 2012; Scholten et al, 2015). Symptoms usually localize to one or the other hip, but can radiate.

Treatment options include both nonoperative and operative interventions. Non-surgical management has been poorly defined inconsistent outcomes reported (Caudil et al, 2008; Larson, 2014). Corticosteroid injections have been shown to only provide temporary relief and eventually lead to surgical intervention (Larson, 2014; Paajanen et al, 2011). Surgical intervention has been shown to be more effective than nonsurgical options, however, surgical intervention has risks and may lead to a substantial amount of time loss from competitive play or be season ending (Caudil et al, 2008; Larson, 2014).

ARE THERE ALTERNATIVES TO SURGERY?

Case reports and case series have examined platelet rich plasma and prolotherapy for core muscle injuries.

Platelet Rich Plasma (PRP) Injections

PRP concentrates a patients own platelets from their blood to concentrate healing factors that play a central role in healing (learn more about PRP here)

Zeppieri Case Report

• In a case report of a 17-year-old competitive soccer player, an ultrasound (US)-guided PRP injection was successfully used to treat chronic groin pain. The injury occurred as he planted with his left leg and struck the ball with his right leg. He noted immediate sharp, stabbing pain along his pubic bone. Based on the MRI findings, patient’s subjective complaints and mechanism of injury, and clinical objective findings, adductor related groin pain was diagnosed. Treatment consisted of an US-guided PRP Injection to the right adductor tendon followed by a multi-phased physical therapy program. Full return to sport occurred at six weeks after the injection. Needle tenotomy was then performed, and a total of 5 mL of autologous PRP was injected in 2 aliquots at the tendon insertion near the pubic crest and the musculotendinous junction. By 6 weeks postinjection, he was given clearance to begin sport-specific training and modified practice. He returned to full pain-free play at his previous level of intensity 8 weeks after the injection, including an entire Division I lacrosse season (Zeppieri et al, 2024).

Scholeten Case Report

• In one report of a 20-year-old Division I collegiate lacross player, PRP was used to treatment athletic pubalgia symptoms (distal rectus abdominis tendinopathy) with an US-guided needle tenotomy and platelet-rich plasma (PRP) injection. He had a history of gradual onset lateral left hip pain with a positive “C-sign” and groin pain that radiated to the left testicle. He had magnetic resonance imaging (MRI) findings, and a positive response to an intra-articular left hip injection with corticosteroid and anesthetic. He subsequently underwent arthroscopic labral debridement. Postoperatively, his left antero-lateral hip pain improved, however, his groin
  pain persisted. In this case, the patient returned to pain-free play at his previous level of intensity after the injection (Scholeten et al, 2015).

Signh Case Report

• In another case report of a 28-year-old soccer player, a complete adductor longus tendon tear was successfully treated with 2 PRP injections and returned to soccer without symptoms. The patient was adducting his leg while cutting to the right, carrying the soccer ball with his left foot, when he was struck by an opposing player. The tendon tear resulted from this eccentric load, and he immediately felt a severe pain in his left groin and heard a “popping sound.” An MRI revealed a complete tear of the left adductor longus tendon from its insertion at the anterior surface of body of pubis as well as high grade muscle strain. Two sets of US-guided PRP injections were planned six weeks apart. The patient had 7cc of autologous PRP mixed with fibrinogen injected directly into the adductor longus tendon under ultrasound visualization. The patient returned to the clinic six weeks later for the second injection and discharged to outpatient therapy.(Singh et al, 2010).

St-Onge Case Report

• In a case report of a 31-year old professional hockey player, PRP injections successfully treated a tear in the rectus abdominis, rectus sheath and a portion of the conjoint tendon. He described as a tight groin and hip flexor, which responded well to stretching, but would tighten up quickly with skating. During a practice session, he felt an acute sharp pain after a slap shot. He received an MRI that night, which revealed a tear in the left rectus abdominis, rectus sheath and a portion of the conjoint tendon. The patient was treated with an ultrasound-guided PRP injection and 1-week a second PRP injection was administered. Full return to play occurred in the middle of week three. (St-Onge et al, 2015).

Park Case Report

• In a case report we published, a case of isolated osteitis pubis without overlapping rectus abdominis or adductor tendon involvement was successfully treated with an ultrasound-guided PRP injection of the pubic symphysis fibrocartilage. The initial injury occurred after he slipped and landed in a split position. The initial MRI of his left hip showed degenerative changes of the symphysis pubis with osteophytes and edema of the pubic body and rami bilaterally. He was treated conservatively with 6-months of massage, anti-inflammatory medication, and physical therapy. Diagnostic blocks were performed, and given the disproportionate relief with the injection into the pubic symphysis compared with the adjacent ligaments, a PRP injection was performed targeting the pubic symphysis. At his 8-week follow-up, he had returned to soccer and his previous level of play (Park et al, 2020).
  

Prolotherapy Injections

Topol Case Report

• In a series of 24 elite soccer and ruby players with chronic groin pain from osteitis pubis and/or adductor tendinopathy, monthly prolotherapy injections were administered and 22 of the 24 players returned to sport without pain. Patients had experienced groin pain for a mean of 15.5 months (range, 6–60mo) and physical examination showed that all had evidence of both osteitis pubis and adductor tendinosis. The concentration of dextrose used was 12.5%. (Topol et al, 2005).

RESOURCES

1. Caudil P, Nyland J, Smith C, Yerasimides J, Lach J. Sports hernias: A systematic literature review. Br J Sports Med. 2008;42:954-964.
2. Drager J, Rasio J, Newhouse A. Athletic pubalgia (Sports Hernia): Presentation and treatment. Arthroscopy. 2020;36(12):2952-2953.
3. Elattar O, Choi H, MD, Dills VD, Busconi B. Groin injuries (athletic pubalgia) and return to play. Sports Health. 2016;8(4):313-323.
4. Larson CM. Sports hernia/athletic pubalgia: Evaluation and treatment. Sports health. 2014;6(2):139-144.
5. Meyers WC, Yoo E, Devon ON, et al. Understanding “sports hernia”(athletic pubalgia): The anatomic and pathophysiologic basisfor abdominal and groin pain in athletes. Oper Tech Sports Med 2012;20:33-45.
6. Ozkan, O., Torgutalp, S. S., Karacoban, L., Donmez, G., & Korkusuz, F. (2020). Do Pain and Function Improve after Dextrose Prolotherapy or Autologous Platelet-Rich Plasma Injection in Longstanding Groin Pain?. Montenegrin Journal of Sports Science and Medicine, 9(2), 5-12.
7. Paajanen H, Brinck T, Hermunen H, Airo I. Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: A randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman’s hernia (athletic pubalgia). Surgery. 2011;150(1):99-107.
   
8. Park DJ, Sussman WI. Osteitis Pubis Treated With Platelet-Rich Plasma: A Case Report. Clin J Sport Med. 2022 Mar 1;32(2):e172-e174.
9. Scholten PM, Massimi S, Dahmen N, Diamond J, Wyss J. Successful treatment of athletic pubalgia in a lacrosse player with ultrasound-guided needle tenotomy and platelet-rich plasma injection: a case report. PM R. 2015 Jan;7(1):79-83.
10. Singh JR, Roza R, Bartolozzi AR. Platelet rich plasma therapy in an athlete with adductor longus tendon tear. Univ Penn Orthop J 2010;20:42-43.
11. St-Onge E, MacIntyre IG, Galea AM. Multidisciplinary approach to non-surgical management of inguinal disruption in a professional hockey player treated with platelet-rich plasma, manual therapy and exercise: a case report. J Can Chiropr Assoc. 2015 Dec;59(4):390-7.
12. Topol GA, Reeves KD, Hassanein KM. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil. 2005 Apr;86(4):697-702.
13. Zeppieri G, Smith MS, Roach RP. Nonsurgical Management of Adductor-related groin pain with Ultrasound-Guided Platelet-Rich Plasma Injection and Physical Therapy in a Competitive Soccer Player: A Case Report. IJSPT. 2024;19(7):898-909.